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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
AamEl.EMiohael Q~~SURNAME
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, depose and S ,that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal ImJ?EliiQ1ent eXists
as to my right to enter into the m lage st 0 ~ /! f L,.-J)~ _ '"' \......)
21, SIGNATURE OF GROOM~ r 22 SIGNATURE OF BRIDE~/:JJ..f~~" ~(2t]27r;z,
~UR AME ?Jt USE CURRENT NAME
23 SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE E A' /l ~ . c'h, 08/22/2008
SIGNATURE OF TOWN OR CITY CLERK ~ _ I.JI!:.. flc ~ DATE ----------
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) IOM..J; ~~~&J:Son
{ SEAL SIGNATURE~ 'ciILP,lrv:l. jl~ ~ DATE 08/221?OOR
MAILING ADDRESS, I ' AM
'-v-I STRtW l\JIidrllet;ti!::h RrI, \N~r!]~'JfJ0J~ F~II~ 'ST~J' 1259qlP 02:42 PM 08
~~~R~:Ri~~~ lo~O~~~N:,zi~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~L1GIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED. S,'O PM q Clo Or 90 OTHER, SPECIFY
29. OFFICIANT :....... L' '-/' 6h? ~()", I. ' ,.....
NAME (PRINT) t:=.....rr.' ~ ... ~ TITLE
SIGNATURE~ ~ I~~~ DATE
MAILING ADDRESS ..c::r., /' #1 P ~ . .
.;' 0 = CIO C>-'7/1. /C! ~.tTL/
CITYfTOWN
COUNTY Dutchess
CITYfTOWN \^'appingEH
DISTRICT . .
~~~~~~R1368
NUMBER 11 3
1. A FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
0, SOCIAL SECURITY NUMBER 056 7" 7222
2. RESIDENCE A. NV B. n, .+",hess
ISTATE) '"1~jElj?Fi')
C. CHECK ONE 0 CITY JJ TOWN 0 VILLAGE
AND
SPECIFY Wappinger
o STREET ADDRESS 5 '^'ildwood Drille, Apt 8D ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..l] NO
McO~ / 6'r.9 / ~~3
3. A. AGE 25
4. EMPLOYMENT
3B. DATE OF BIRTH
~
:;
c:c
c
u:
A. USUAL OCCUPATION Commissions Analyst
B. TYPE OF INDUSTRY OR BUSINESS Finiilnce
5 PLACE OF BIRTH <;:i>>' sQt Fc~~J5.~,iiA~ ie, Ny
6. FATHER
A. NAME Gregory James Dick
B. COUNTRY OF BIRTH U S IJ.
7. MOTHER
A. MAIDEN NAME Amy Melody Gleiiilion
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Nicole ~~beth HO~WA~URNAME
-.J
11. A, FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. S~S~*~Mr-~~rt~~C~~~ick
D. SOCIAL SECURITY NUM8ER 07 A.-RR-RR~R
12. RESIDENCE ANY(STATE) B D~tw;ss
C. CHECK ONE 0 CITY..2J TOWN 0 VILLAGE
AND '^' '
SPECIFY applnaer
o STREET ADDRESti Wilrlwood Drive, Apt 8d ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES~ NO
13. A. AGE26 3B. DATE OF BIRTH ~TH ~iAY .1~g~
14. EMPLOYMENT
A. USUAL OCCUPATION Data Entry
B. TYPE OF INDUSTRY OR BUSINESS Non Profit
15. PLACE OF BIRTHYonk~r~ N.li
(CITY. STATE / tOUNtRY IF NOT USA)
16. FATHER
A. NAME Peter Holowiak III
'B. COUNTRY OF BIRTt-l1 S A
17. MOTHER
A. MAIDEN NAME Ann~ 7ofi~ Pi~k;:)r7'
B. COUNTRY OF BIRTff!ol~nrl
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
o
DEATH
n
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
"
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF.DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
TIME
MONTH
YEAR
DAY
YEAR
DAY
MONTH
23
2008
21 2008
10
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY f1c/tn''I4irL
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
....,/
STATE
err
~' d' ,)'?J \.
ZIP
CEREMONY
SPECIFY C "t. 1)
5 f'k.? III./~-